Provider perceptions of limited health literacy in community health centers
Introduction
Community health centers (HCs), as the nation's major safety net health care providers for over 15 million people, face significant challenges treating patients with limited health literacy (LHL) [1]. The majority of HC patients are low income (91%), uninsured (40%) or publicly insured through Medicaid (36%), and racial and ethnic minorities (63%) [1]. Furthermore, nearly one-third of all HC patients are best served in a language other than English [1].
The 2003 National Assessment of Adult Literacy (NAAL), a large, nationally representative survey, found that 22% of US adults had no better than basic health literacy, while 14% had below basic health literacy, corresponding to being non-literate in English or having no more than the most simple and concrete literacy skills. This survey found that Black and Hispanic adults, non-native English speakers, older adults, those with less than a high school education, and adults living below the poverty level had lower average health literacy [2]. LHL has been linked with health outcomes such as self-reported poor health, increased risk of hospital admission, diagnosis of disease at later stages, poor adherence to medication regimens, and poorer disease knowledge and outcomes [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]. Schillinger et al. found that among patients with type 2 diabetes attending a public hospital's primary care clinics in San Francisco, CA, USA, inadequate health literacy was associated with worse glycemic control and higher rates of retinopathy [11]. Furthermore, LHL has been shown to be associated with higher health care costs among adult Medicaid patients [13].
While there is much anecdotal evidence of LHL affecting patient care in HCs, we are aware of only one health literacy study conducted in this setting, in a single rural HC. This study had a small sample size (N = 70), and examined patients’ functional health literacy. Fifteen percent of participants in this study scored in the inadequate and marginal functional health literacy ranges on the test of functional health literacy in adults (TOFHLA) [14]. We were unable to identify any studies which specifically examined HC providers’ perceptions of how LHL affected their patients and what methods they used to identify and help patients with LHL. Therefore, our objectives were to determine provider estimates of LHL prevalence in HCs, how HC providers are screening and assisting patients with LHL, what programs they believe would be effective, and what barriers they foresee to implementing interventions.
Section snippets
Methods
The MidWest Clinicians’ Network (MWCN) is a non-profit corporation consisting of approximately 100 HCs, primary care associations, individual providers, and other partners within 10 Midwestern states [15]. MWCN's mission is to enhance professional and personal growth of clinicians so they can become effective leaders in their health centers and promoters of quality, community-based primary health care [15]. MWCN organizational members may be federally qualified community health centers,
Respondent and health center characteristics
Three hundred and thirty-three out of 701 eligible respondents completed and returned surveys for an overall response rate of 47.5%. The response rates for the first, second, and third survey mailings were 24.0%, 16.1%, and 17.7%, respectively. Forty-seven (96%) of the 49 participating centers returned data. The majority of respondents were either physicians (43%) or nurse practitioners (20%). Fifty-eight percent of the respondents were female, 74% were white, and the mean ± S.D. age was 45 ± 11
Discussion
Providers at HCs estimated the prevalence of LHL to be quite high among their patients, with the average percent reported for English- and Spanish-speaking patients being 41% and 48%, respectively. These estimates are similar to the results found in the 2003 National Assessment of Adult Literacy, where 36% of all adults were found to have basic or below basic health literacy, with the percent being higher among patients receiving Medicaid (60%), those with no insurance (53%), and among Black
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Acknowledgements
This project was supported by the National Institute of Diabetes and Digestive and Kidney Diseases Diabetes Research and Training Center (P60 DK20595). Dr. Chin is supported by a Midcareer Investigator Award in Patient-Oriented Research from the National Institute of Diabetes and Digestive and Kidney Diseases (K24 DK071933). Dr. Heuer is a Robert Wood Johnson Executive Nurse Fellow Alumni and an American Academy of Nursing Fellow.
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Currently with the University of Michigan School of Public Health, United States.